Wound Healing 1. inflammatory phase 2. proliferative or granulation phase 3. maturation, or wound remodeling, phase

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Wound Healing1. inflammatory phase2.
proliferative or granulation phase3.
maturation, or wound remodeling, phase

• WOUND CARE

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Wound Classification

• BY CAUSE 1. intentional
• 2. unintentional
• CLEANLINESS 1. clean
• 2.
  contaminated
• 3.
  infected
• DEPTH 1. superficial
• 2. partial thickness
• 3. full thickness
• COLOR - by using the RYB Classification.

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The RYB Classification System

• Classifies open wound s that are healing by
  secondary or delayed primary intention in both
  chronic or acute wounds.
• It can be used to determine the state of healing.
• Red wound s- can be in inflammatory,
  proliferative or maturation stage.
• Yellow wound infected, contain fibrogenous
  slough.
• Black wound contain necrotic tissue. Not ready
  to heal.

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Types of Wound Healing

• Primary Intention simplest form of wound
  healing. Skin is cleanly incised. e.g. surgical
  incision or traumatic laceration. Closed with
  suture or staples.
• Secondary Intention The wound heals by
  granulation. Granulation tissue builds, it fills
  the gap under the skin and cells epithelize from
  edge of the wound to create the closure.
• e.g. burns, pressure ulcers and wounds with
  large piece of skin missing.
• Tertiary Intention leaves open wound to heal.
  Wound cannot be sutured. Dehiscence occurred or
  wound is infected.

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Major Factors Affecting Wound Healing

• Nutrition
• General Physical Health
• Medications

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Goals of Wound Care

• Remove necrotic tissue and promote wound healing.
• Prevent, eliminate, or control infection.
• Absorb drainage (exudate).
• Maintain a moist wound environment.
• Protect the wound from further injury.
• Protect the surrounding skin from infection and
  trauma.

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Associated With Wound Healing Complication

• Adhesions
• Incisional strangulated internal hernias
• Contractures shortening of the scar tissue.
• Wound Infections

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Wound Infection prevention

• Use of semi-occlusive dressing reduced incidence
  of infection, promotes moist environment.
• Observation of Standard Precaution.
• Proper Hand Hygiene.
• Maintaining Asepsis during wound dressing.
• Using sterile supplies and equipment.
• Clinical S/S of Infection generally begin 3-5
  days post-operatively or following the injury.

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S/S of Wound Infection

• Progressively more tender wound
• Painful
• Edematous
• WBC count of 12, 000/mm3 or greater lasting
  longer than 72 hours.
• Foul smelling and purulent drainage.

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Microorganism Causing Wound Infection

• Staphylococcus Aureus - major
• Escherichia Coli
• Streptococcus faecalis
• Proteus Vulgaris
• Klebsiella
• Enterobacter
• Pseudomonas Aerogenusa
• Wound Specimen for Culture Dx test.

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Measures to Prevent Infection

• Completing Surgical hand Hygiene
• Donning Sterile Gloves
• Pouring from Sterile Container
• Equipment Sterile container
• Non sterile
  container
• Sterile Solution
• Procedure See accompanying procedure.